Effectively treating homeless persons with co-occurring disorders involved in the criminal justice system
Biopsychosocial challenges confront homeless persons involved in the criminal justice system, especially when they have co-occurring mental health and substance abuse disorders. In this article, the Criminal Justice Treatment for Homeless Workgroup, a group comprising program and evaluator professionals working in homeless projects funded through the Substance Abuse Mental Health Services Administration, focuses on lessons learned while enhancing successful recovery strategies for this vulnerable group of people. Providing services to such homeless persons adds complexity to the treatment of their risks and needs. Specific criminal justice issues include court orders, legal restrictions, access to prescribed medications, medication adherence, probation and parole supervision, information-sharing requests, and navigation of multiple systems with different professional cultures, expectations, and languages. Homeless persons also face challenges to recovery beyond typically addicted persons, such as negative public and professional attitudes, addiction- and criminal-thinking patterns, stressed or destroyed family relationships, drug abuse and other risk behaviors, and negative criminal justice and street cultures. In this article, five areas emerge from the literature and professional experience that are essential to successful treatment and recovery: communication, collaboration, clinical and recovery interventions, care coordination, and comprehensive evaluation.
Authors Note: This paper was prepared by members of the Criminal Justice Treatment for Homeless Workgroup, which is one of nine workgroups developed through Technical Assistance funded by the Substance Abuse Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT), Co-Occurring and Homeless Activities Branch (CHAB). Each workgroup consists of members who represent sites receiving funding under the Treatment for Homeless initiative and is supported by a CSAT Project Officer and contractual staff who provide facilitation and technical assistance. The authors developed this brief overview of issues to share their experiences and perspective but also to solicit feedback and reactions from others who serve these populations. The group’s goal is to expand further on these ideas in a full-length article, and readers are encouraged to contact Rick Esterly (610-763-0821, email@example.com). This paper was authored by the following workgroup members: Rick Esterly, MHS, FACATA (Gaudenzia, Inc./Esterly Consulting Associates); Steven Neumiller, MA, NCC (Inland Northwest Proposal Development); David Freeman, PsyD (Community Connections, Inc.); Ali Manwar, PhD (SAMHSA); Susan Brumbaugh, PhD (RTI International ); Jennifer Hardison Walters, MSW (RTI International); Erin O’Brien. MA (Palladia, Inc.); and Kay Calendine, BS (Pima Prevention Partnership). This product was developed in part from information from the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). The views, policies, and opinions in this document do not necessarily reflect those of SAMHSA or HHS.
Effectively Treating Homeless Persons with Co-occurring Disorders Involved in the Criminal Justice System
Rick Esterly, Steven Neumiller, David Freeman, Ali Manwar, Susan Brumbaugh, Jennifer Hardison Walters, Erin O’Brien, Kay Calendine
Introduction: The purpose of this brief paper is to contribute to the understanding of—and to facilitate resolution of—problems related to the intersection of criminal justice, substance abuse, mental health, homelessness, and trauma and physical abuse. The authors include staff currently implementing and evaluating programs that deliver services to persons who are homeless, who have co-occurring disorders, and who are involved in the criminal justice system. This paper outlines lessons learned from working with this population and presents strategies that, if implemented, will enhance successful recovery of this vulnerable population. This product was developed in part from information from the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). The views, policies, and opinions in this document do not necessarily reflect those of SAMHSA or HHS.
Overview: Substance abuse and mental health disorders present complex biopsychosocial challenges—all the more complicated and potentially disabling when they occur together. These co-occurring disorders must be addressed on all levels—substance abuse, mental health, physical/medical, social, legal, employment, and values/beliefs/spiritual—with a special focus on traumatic victimization and its long-term effects. A history of trauma or victimization can contribute to a person becoming involved in the criminal justice system, and traumatization or victimization can occur during incarceration. Substance abuse, mental health, and other on-site and community treatment professionals such as counselors and case managers—including trauma-informed specialists; physicians; nurses; psychiatrists; psychologists; and recovery support professionals representing housing, criminal justice, employment, education, and training—are integrated into the service plan, interventions, and recovery support activities.
Although some areas are a matter of emphasis or focus (e.g., housing, recovery support), providing services to the person with a co-occurring disorder who is involved in the criminal justice system raises its own specific issues: availability of and access to prescribed medications when incarcerated and upon release; medication adherence; court orders; probation and parole supervision; legal restrictions; information-sharing requests; and navigation of multiple systems with different cultures, expectations, and professional languages. This paper focuses on five essential areas in providing services for this population: communication, collaboration, clinical and recovery interventions, care coordination, and meaningful evaluation.
Barriers to Recovery: Homeless persons who have co-occurring disorders and who are involved in the criminal justice system face challenges to recovery, such as:
• Negative attitudes from the public toward mental illness, as well as discrimination based on one’s gender, race, language, educational background, or age;
• Addictive and criminal thinking that may result in manipulation or disregard for others’ feelings or property;
• Culturally specific behaviors, beliefs, norms, or value systems such as posturing, expressed emotions, body coding, time orientation, or importance of family;
• Stressed or destroyed family relationships and spirituality;
• Risk behaviors like multiple drug abuse; and
• Negative culture of the criminal justice system, jails, homelessness, and substance abuse.
The impact of chronic traumatic victimization interweaves with other problems (like the culture of incarceration) and in turn, affects hope, purpose, meaning, motivation, sense of the future, and concern for personal well-being and the well-being of others. Understanding these issues and training staff in these areas are essential to effective engagement and retention.
Areas Essential to Successful Treatment and Recovery: On the basis of a review of research coupled with extensive relevant experience, the authors have identified five areas that are essential to successful treatment and recovery of persons with co-occurring disorders who come in contact with the criminal justice system: communication, collaboration, clinical and recovery interventions, care coordination, and comprehensive and meaningful evaluation.
1. Communication is the exchange of information between people by means of speaking, writing, or using a common system of signs or behavior. It is the basis of addressing the strengths and needs of the homeless person with a co-occurring disorder who is involved in the criminal justice system. Treatment and criminal justice professionals must communicate with each other about a variety of information pertaining to the client, including their impressions, clinical assessment strategies and results, collateral information, justice system requirements, and treatment recommendations and plans. They must use a common language to discuss their approaches, planned interventions, and stages of treatment and stages of change. Criminal justice system supervision restrictions and dictates must be balanced with treatment needs and plans.
For example, a treatment staff person may not be aware of the client’s involvement in the criminal justice system and may be willing to overlook a single positive urine test or address it in a therapeutic approach. The parole officer may be aware of other positive urine tests but has not shared these occurrences. The officer may have a court order to return the person to prison or a community correction center on the first positive urine test. As with drug court cases, all professionals must agree to a course of action. With appropriate signed releases, communication may occur through a combination of weekly treatment team meetings, telephone calls, and face-to-face meetings among staff and community partners.
2. Collaboration: Based on effective communication, collaboration is the process of converting information to the planning for and implementation of interventions. It occurs between the treatment staff members, criminal justice system representatives, and community-based service providers to allow for sharing goals, requirements, responsibilities, and decision making.
For example, the homeless person who has a co-occurring disorder and who is involved in the criminal justice system may have an employment opportunity but have a parole reporting requirement that would preclude taking the job. Or the treatment staff may not believe that a client on medication for depression or other psychiatric disorder is ready for full-time employment. If the treatment staff and parole officer have a trusting relationship, they may easily discuss these situations and come to a workable agreement. The overarching goal must be the client’s success as defined and perceived by the criminal justice system with substantial input from the client. The client is empowered when all staff and community partners share common goals, objectives, priorities, and interventions, with the understanding that the client is at the epicenter of this activity but is not the controlling factor. The criminal justice system, in collaboration with the other partners in the client’s recovery, should be appropriately respectful of and accommodating to the client’s self-directed goals.
Collaboration includes an attempt to recruit staff and community partners who share a treatment and service philosophy and approach—the most important being that treatment can be effective, that most people want the same things in life (e.g., safety, security, belonging, love), and that people can and do change. Internal and cross-agency training fosters this consistency. A steering committee or community case management committee with treatment, criminal justice, consumer, and recovery support partners will serve to provide open and honest feedback and direction, improve collaboration, and address system issues.
3. Clinical and Recovery Interventions: To the extent possible, treatment and community partners should explore and use evidence-based practices and interventions that are philosophically consistent, coordinated, and culturally appropriate for the population. Clinical decision making regarding the multifaceted needs of homeless persons with co-occurring disorders involves issues and trade-offs related to participant, community, and criminal justice system values, culture, and competing priorities. Multiple medical, financial, social, family, housing, and employment issues, combined with histories of trauma and abuse, compound the complexity. An effective approach that may address these concerns is the “multiple streams of evidence’’ approach (Reed, 2005), which addresses three components of evidence-based practices:
a. best research evidence, which is clinically relevant research that addresses evolving criminal justice system principles; clinical practices such as cognitive behavioral therapy, motivational enhancement therapy, and self help; and client-centered therapeutic approaches, such as the therapeutic community, intensive outpatient, and regular outpatient therapy;
b. clinician expertise, which is the ability to use clinical skills, past experience, and practice-based evidence to adapt evidence-based practices and effectively treat individuals; and
c. patient values, which is the integration into treatment planning of the preferences, concerns, and expectations that each person brings to the clinical encounter (CSAT, 2006).
4. Care Coordination: As defined above, effective communication and collaboration will foster care coordination, the long-term implementation of an integrated plan. Care should be integrated at the clinical, program, and system levels; staff development, cross-training, and retention are interrelated tools to achieve this element. Engaging and developing client-centered goals and objectives must be coordinated in a way that participants find helpful over the long term. Developing a clear path to success (with, for example, a coherent schedule of expectations) can help motivate the person. Individualized needs are accurately assessed, personally prioritized, and timely addressed in a planned manner. A single case manager or well-coordinated team oversees the coordination of treatment and recovery support services.
For example, many clients are suspicious and distrusting; they deal with low self-esteem and societal negative attitudes toward them. Time and patience are required for the client to know what the issues are and what can be addressed. Clients may be in deep denial regarding medical and substance abuse or mental health disorders.
If the client is not in a residential program, then a multidisciplinary team of treatment staff and community professionals must address immediate housing, medical, substance abuse, and mental health areas with equal attention. Only then can the client be motivated to address long-term recovery support services, including employment, education and training, and stable housing. The value of services delivered to clients is maximized when treatment and recovery support services are coordinated across service professionals (treatment team, community service providers, facility staff, probation and parole officers), functions (medical, mental health, and substance abuse treatment; housing; employment), activities (groups, counseling sessions, workshops), and sites (project facility, community).
5. Comprehensive and Meaningful Evaluation: Evaluations that yield meaningful findings for the program, organization, and funding entities can inform the program’s decision making process. Meaningful evaluation includes identifying issues and problems and constantly looking for ways to improve the program’s outreach, treatment, and recovery services. Process and outcome evaluation methods produce a thorough assessment of the program’s performance. A process evaluation measures the efficiency and effectiveness of both the program and organization procedural activities. Outcome evaluations assess the extent to which the program has impacted its clients, including the clients’ satisfaction with the services they received.
An evaluation analysis may show important differences between clients who are involved in the criminal justice system and those who are not. For example, criminal justice-involved clients may be less likely to complete the program because of differences in demographics and risk factors (e.g., age is a risk factor for completion). An analysis of intake assessments may find that criminal justice–involved clients have more, or more severe, co-occurring disorders or that the co-occurring disorders are not being addressed adequately. Information in client histories may help explain some negative outcomes. For example, a woman may be unable to work with a male counselor because of previous victimization or betrayal by a male authority figure. Satisfaction surveys and interviews may reveal that a certain staff member is not retaining most of his or her clients.
In closing, after years of stagnant approaches to treatment of the homeless, the field is evolving quickly. For the benefit of clients, treatment professionals must all take advantage of educational opportunities to keep up with changing technology, pharmacology, treatment approaches. Lastly, especially in light of evolving health reforms, professionals should be aware of, engaged in, and advocate for the development of policies that affect individuals who are homeless, criminal justice-involved, and with co-occurring disorders.
Center for Substance Abuse Treatment. (2006). Treatment, Volume 1: Understanding Evidence-Based Practices for Co-Occurring Disorders. SAMHSA’s Co-Occurring Center for Excellence Overview Paper 6. DHHS Publication. Rockville, MD: Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services. http://coce.samhsa.gov/cod_resources/PDF/Evidence-BasedPractices%28OP6%29.pdf
Reed, G. M. (2005). What qualifies as evidence of effective practice? Clinical expertise. In J. C. Norcross, L. E. Beutler, & R. F. Levant (Eds.), Evidence-based practices in mental health: Debate and dialogue on the fundamental questions. Washington, DC: American Psychological Association.
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